Sm-09-03-03 - association between smoking.pmd
Smoking and minimal–mild depressive symptomatology in heavy smokers
Association between smoking and minimal–mild
depressive symptomatology in heavy smokers
Ana Moreno Coutiño,¹ Silvia Ruiz Velasco,² María Elena Medina-Mora Icaza3
severity of tobacco addiction (p= .025). Those with a bachelor’seducational level, had less depressive symptomatology (p= .025).
The World Health Organization (WHO) estimates that by the year
The high frequency of depressive symptomatology and the protective
2020 tobacco addiction will be responsible for 10 million deaths,
factor of schooling concur with findings reported in other studies.
seventy percent of which will occur in underdeveloped countries. On
The better understanding of the characteristics of smokers with
the other hand, depression affects about 121 million people
different levels of tobacco consumption and depressive
worldwide, and is projected to reach a second place in the ranking
symptomatology is suggested. It is important to gain knowledge on
of Disability Adjusted Life Years (DALYs) calculated for all ages and
the particular characteristics of specific groups of smokers for the
development of new treatments that can simultaneously treat smoking
In Mexico, 14 million people are current smokers and 9.6 million
addiction and depression, and can also help to norm criteria for
are former smokers, according to the 2002 National Addictions
Survey, and almost four million people are diagnosed with depression.
Both disorders are classified among the main causes of mortality
Key words: Smoking, depression, sociodemographic characteristics.
and disability in Mexico. By gender, major depression in females isthe second most prevalent disorder. Two percent of the Mexicanpopulation (two million people) present at least one major depressive
episode before reaching the age of 18. Several studies have foundan important link between depression and smoking. More recently, it
La Organización Mundial de la Salud (OMS) estima que para el año
was reported that the manifestation of depressive symptomatology
2020 la adicción al tabaco será responsable de 10 millones de
predicts smoking addiction. Although the strong association between
muertes, 70% de las cuales ocurrirá en los países subdesarrollados.
affective disorders and drug abuse has been documented, they are
La mitad de los fumadores actuales, aproximadamente 650 millo-
generally treated independently. For this reason, the need for integral
nes de personas, morirá debido a una causa relacionada con el
management of comorbid diseases has been highlighted.
consumo de tabaco. Por otro lado, actualmente la depresión afecta
Little is known about specific populations of patients that
a cerca de 121 millones de personas en el mundo, y se ha proyecta-
simultaneously manifest both disorders, and more knowledge is
do que para el año 2020 ocupará el segundo lugar en Años de Vida
needed in order to design precise integral treatments for this kind of
Ajustados por Discapacidad (AVAD) en todos los grupos de edad y
patients, taking into consideration the gender, severity of depression
en ambos sexos. En México, 14 millones de personas son fumado-
res actuales y 9.6 millones son ex fumadores, según la Encuesta
The aim of this study was to describe the association between
Nacional de Adicciones (ENA) 2002, y casi cuatro millones de per-
depressive symptoms, sociodemographic characteristics, and pattern
sonas padecen depresión. Ambos trastornos se clasifican entre las
of tobacco consumption of heavy smokers with minimal-mild
principales causas de morbimortalidad en nuestro país. En cuanto a
depressive symptomatology in order to adjust for these relations in a
las diferencias por sexo, en las mujeres, la depresión es el segundo
later longitudinal regression analysis after these subjects have been
trastorno más frecuente. El dos por ciento de la población mexicana
assigned to different conditions of a new integral treatment to quit
(dos millones de personas) ha padecido por lo menos un episodio de
smoking. A total of 89 heavy smokers were assessed; 74 of them
depresión importante antes de alcanzar la edad de 18 años. Varios
(83%) had minimal-mild depressive symptomatology; there were 35
estudios han encontrado una asociación importante entre la depre-
females and 39 males, with an average age of 44.3 yrs. Level of
sión y el tabaquismo. Recientemente se reportó que la manifestación
tobacco addiction was determined by the Fagerström Test for Nicotine
de la sintomatología depresiva predice la adicción al tabaco.
Dependence, and the Beck Depression Inventory was used to assess
De acuerdo con varios estudios, se sabe que la nicotina reduce
depressive symptomatology. By means of regression models, we
la incidencia y la gravedad de los síntomas depresivos y que la
found an increase of the depressive symptomatology related to the
abstinencia del tabaco puede desencadenar síntomas depresivos,
¹ Facultad de Psicología, UNAM.
² Departamento de Probabilidad y Estadística. Instituto de Investigaciones en Matemáticas Aplicadas y Sistemas (IIMAS), UNAM, México.3
Directora General. Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz. Calz. México-Xochimilco 101, San Lorenzo Huipulco, Tlalpan, 14370,México D.F.
Correspondencia: Dra. Ana Moreno Coutiño. Av. Universidad 3004, Col. Copilco-Universidad, Del. Coyoacán, 04510 México D.F. Tel. 5658 3911.
Fax.5658 3744. E-mail: email@example.com
Recibido: 3 de diciembre de 2008. Aceptado: 9 de febrero de 2009.
por lo que se ha sugerido que las personas con depresión fuman a
mujeres y 39 hombres, con una media de edad de 44.3 años. El
manera de automedicación contra la sintomatología depresiva.
nivel de adicción al tabaco fue determinado por la prueba de
A pesar de que ha sido documentada la fuerte asociación entre
Fagerström para la dependencia a la nicotina, y se usó el Inventario
los trastornos afectivos y las adicciones, estos trastornos se atienden
de Depresión de Beck para determinar el nivel de sintomatología
generalmente de manera independiente. Por esta razón, se ha
depresiva. Mediante un modelo de regresión, encontramos un
subrayado la necesidad de generar tratamientos integrales para los
aumento de la sintomatología depresiva relacionada con la gravedad
de la dependencia al tabaco (p=.025). Aquellos con nivel de
Hasta el momento, se sabe poco sobre poblaciones específicas
enseñanza de licenciatura presentaron menos sintomatología
de pacientes que de manera simultánea son adictos al tabaco y
depresiva (p=.025). Los principales resultados de este estudio son
padecen sintomatología depresiva, por lo se requiere de mayor
la asociación significativa entre el nivel de dependencia al tabaco y
entendimiento de sus características para diseñar tratamientos
la sintomatología depresiva en fumadores fuertes. Tanto la alta
integrales específicos para este tipo de pacientes. Para ello se debe
incidencia de la sintomatología depresiva como el factor protector
tomar en consideración el sexo, la gravedad de la depresión y el
de la enseñanza concuerdan con los reportes de otros estudios con
nivel de dependencia de la nicotina.
El objetivo del presente estudio fue describir la relación que
Es importante conocer las características particulares de grupos
existe entre los síntomas depresivos, las características
específicos de fumadores para desarrollar nuevos tratamientos que
sociodemográficas y el patrón de consumo de tabaco en fumadores
pueden tratar simultáneamente la adicción al tabaco y la depresión,
fuertes con sintomatología depresiva mínima leve para ajustar dichas
así como para ayudar a normar criterios para su tratamiento. Se
relaciones mediante un modelo de regresión longitudinal, en un
sugiere continuar ahondando en el conocimiento de las características
estudio posterior, donde los pacientes serán asignados a diversas
de los fumadores con diversos niveles de consumo de tabaco y
condiciones terapéuticas de un nuevo tratamiento integral contra el
Un total de 89 fumadores fuertes fueron evaluados; 74 de ellos
Palabras clave: Tabaquismo, depresión, características
(83%) padecían sintomatología depresiva mínima leve; había 35
More recently, it was reported that the manifestation
of depressive symptomatology predicts smoking
Worldwide, tobacco addiction is one of the main causes of
addiction.14 To determine the probability of substance abuse
preventable morbi-mortality and low quality of life; and it
co-occuring with affection disorders, a study found that
is also responsible for five million deaths per year (one out
the latter occurred before substance abuse or dependence
of 10 adult deaths worldwide). Half of the current smokers,
approximately 650 million people, will die due to a cause
Some of the differences between genders have been
related to tobacco consumption. If these tendencies persist
addressed. Women smokers are two times more likely to
by the year 2020, the World Health Organization (WHO)
present depression symptomatology compared to non-smo-
estimates that tobacco addiction will be responsible for 10
king women, and five times more likely than men, while
million deaths, 70% of which will occur in underdeveloped
men who smoke more than one pack a day are five times
countries. On the other hand, depression affects about 121
more likely to manifest depression symptoms compared to
million people worldwide, and is projected to reach a
non-smoking men. Current and former smokers are more
second place in the ranking of Disability Adjusted Life Years
likely to present depression compared to those who have
(DALYs) calculated for all ages and both sexes by the year
2020. Today, depression is already the second cause of
Although the strong association between affective
DALYs in the 15-44 age range for both sexes combined.1
disorders and drug abuse has been documented, they are
In Mexico, 14 million people are current smokers and
generally treated independently. For this reason, the need
9.6 million are former smokers, according to the National
for integral management of comorbid diseases has been
Addictions Survey,2 and almost four million people are
diagnosed with depression. Both disorders are classified
Based on several studies, we know that nicotine redu-
among the main causes of mortality and disability.3 By
ces both the incidence and severity of depressive
gender, major depression in females is the second most
symptoms19-23 and that tobacco abstinence can uncover
prevalent disorder. Two percent of the Mexican population
depressive symptoms.23 More specifically, when these
(two million people) present at least one major depression
appear during the sixth week and sixth month of abstinence
episode before reaching the age of 18.4 The peaks of incidence
reincidence in smoking is expected.24 This correlates with
for major depression are approximately at 17, 32 and 65 years.5
results obtained among depressed patients undergoing
Several studies have found an important link between
treatment in which the acceptance of anti-tobacco therapy
depression and smoking.6-12 Smokers with a history of
depression tend to relapse into depression when trying to
It has been proposed that people with depression
smoke as a form of automedication against depressive
Smoking and minimal–mild depressive symptomatology in heavy smokers
symptomatology by using negative reinforcement.20,23,26
this data, information regarding their general pattern of
This explains why, in order to counteract nicotine abstinence
tobacco consumption was collected during the initial
symptoms, the administration of antidepressive drugs, such
interview. The Beck Depression Inventory (BDI) of 21 items
as bupropion and nortriptiline, has positive results.27-32
was used to assess depressive symptomatology.34 The latter
Little is known about specific populations of patients
has been validated for its application among Mexicans, and
that simultaneously manifest both disorders, and more
the Spanish versions of both the FTND and the BDI have
knowledge is needed in order to design precise integral
been extensively used.35-39 Carbon monoxide (CO)
treatments for this kind of patients, taking into
exhalation level and a sample of urine were requested to
consideration the gender, severity of depression and level
corroborate smoking level. To measure the alveolar
concentration of CO in exhalation in ppm (parts per million)
In Mexico, prevalence reports for mild and moderate
a Micro Medical, Micro CO detector, was used. A gas
depressive symptomatology are 23% and 49%, respectively.5
chromatographic-mass spectrometric method was used for
The aim of this study was to describe the association between
the detection and quantification of cotinine in urine, taking
depressive symptoms, sociodemographic characteristics, and
in to account the deuterated internal standard, following
pattern of tobacco consumption in order to adjust for these
the method of Hutchinson et al.40 The analyses were
relations in a later longitudinal regression analysis after
extracted by liquid-liquid extraction coupled to
subjects have been assigned to one of three different
centrifugation and evaporation. The cut-off point for
conditions of a new integral treatment.
cotinine to verify abstinence was 40ng/ml, since theequipment could not verify any lower than that. Thecalibration curve for cotinine was created from 1-10 000
ng/ml. All data were corrected by recovery efficiencies.
The information collected was captured in a data base
for analysis by means of regression models using the Stata10 program, where the dependent variable was the score
A total of 89 heavy smokers —which were Mexican members
obtained in the Beck Depression Inventory and the
of the university community, either students, academics
independent variables were all the sociodemographic va-
(researchers and lectureres), administrative (secretaries,
riables. We used a stepwise procedure to find out the
accountants and functionaries) or support employees
independent variables that had a significant effect on the
(watchmen and maintenance workers)— who attended after
BDI, and included gender, age, and marital status.
being invited for treatment of tobacco addiction at the ClinicAgainst Addictions of the National Autonomous Universityof Mexico (UNAM) were assessed. Heavy smoking was
defined as consuming more than 10 cigarettes per day.
Depressive symptomatology was found in 83 patients
Table 1 shows the sociodemographic characteristics of the
(93%). Minimal-mild symptoms were present in 74 patients
74 heavy smokers included in this study. It also describes
(83%) and heavy depressive symptoms were found in nine
the principal patterns of smoking and depressive
patients (10%). For this study, 15 patients were excluded:
symptomatology. In the whole population, the mean
those with heavy depressive symptoms, three cocaine addicts,
number of cigarettes consumed per day was 18 cigarettes
two pregnant women and one patient with schizoid traits.
(SD 7.6); the age of first tobacco use was 15.46 years (SD
The 74 heavy smokers with minimal-mild depressive
4.33), that for years smoking was 25.39 (SD 10.09), and the
symptoms included in this study were 35 females (47.3%)
level of nicotine dependence, according to the Fagerström
and 39 males (52.7%), with an age average of 44.3 years
test, was 4.73 points (SD 2.21), which corresponds to a
moderate level of dependence. The median of the depressivesymptomatology according to the Beck Inventory was 8.99
points (SD 5.77), which corresponds to a minimal level ofdepression.
Psychologists trained in the rehabilitation of smokers
The p value for categorical variables was calculated
approached smokers through individual and group
with Pearson’s χ² statistic, and continuous variables were
invitations in diverse entities of the university and arranged,
analyzed on a mean difference t-test. It is worth mentioning
for those interested, an appointment for evaluation at the
that both males (n=39) and females (n=35) included in the
Clinic Against Addictions of the UNAM, between February
study were similar in age, school level, working status, age
of first cigarette, years smoking, level of nicotine
The level of tobacco addiction was determined by the
dependence, and depressive symptomatology. The only
Fagerström Test for Nicotine Dependence (FTND).33 Besides
differences found were in the marital status and the pattern
Table 1. Characteristics of severe smokers by gender
Table 2. Beck Depression Inventory and SociodemographicCharacteristics
*significance to 5%, ** significance to 10%.
concordance with the results in studies performed with
different groups of smokers,6-10,41 as well as the significant
relation between the bachelor’s level of education and thedecrease in the Beck Depression Inventory score. Patients with
of smoking behavior, with males reporting a significant
bachelor’s school level were more than five points under those
higher number of cigarettes per day.
with school level lower than high school. A tendency in the
Results of the regression models are shown in table 2.
decrease of depressive symptomatology was also observed
The results of statistically significant variables and the main
in patients with post-graduate degrees, which was probably
sociodemographic characteristics, such as gender, age and
non-significant due to the size of the sample. These findings
marital status, are reported. Variables, such as reasons for
are similar to previous reports that state that education level
smoking initiation, years consuming the current amount
acts as a protective factor against tobacco addiction.42,43
of cigarettes, number of attempts to quit smoking, living
In relation to working status, a marginal protector fac-
and working with other smokers, level of carbon monoxide
tor was found for those in the administrative area,
in exhalation and cotinine urine level, did not reach
compared to support employees. On average, the BDI scores
of the first were almost three points below. This finding
Nicotine dependence level was considered as a
could be related to the connection between educational level
continuous variable, and its effect represents a 0.68 increment
and working status, since almost half of the support
in Beck’s scale for each change of one unit in the level of
employees had lower than high school educational level.
dependence in the Fagerström test, showing that nicotine
Although the level of tobacco dependence and the
dependence was a risk factor for depression. On the other
increment of depressive symptomatology associated
hand, bachelor’s school level and administrative working sta-
significantly, this was not reflected in the variables of carbon
tus are protective factors against depressive symptomatology.
monoxide and cotinine levels, maybe because the time forthe collection of the samples after smoking was not controlled.
In those variables where differences by gender were
significant, such as marital status and number of cigarettesper day, models of regression were adjusted separately by
The main findings of this study are the significant association
gender and no significant differences were found. However,
between the level of tobacco dependence and the increment
most patients that consumed more than one pack of cigarettes
of depressive symptomatology in heavy smokers, in
per day were men. This is consistent with review reports.2,41
Smoking and minimal–mild depressive symptomatology in heavy smokers
These results highlight the need for simultaneous
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PRESERVING SIGHT, SOUND AND OTHER SENSES: The abstracts below show that testosterone, estrogen, aldosterone, cortisone /prednisone, melatonin and antioxidants/ insulin sensitizers have significant protective benefits on hearing and sight, whether longterm or acutely. The Frisinas' work (Univ Rochester) showing that estrogen protects but progestin worsens hearing is news, brought to our at
Name :Nalidixic acid Cas No. :389-08-2 Synonyms:NOGRAM;NALIDIXIC ACID;NALADIXIC ACID;1,4-DIHYDRO-1-ETHYL-7-METHYL-1,8-NAPHTHYRIDIN-4-O NE-3-CARBOXYLIC ACID;1,4-DIHYDRO-1-ETHYL-7-METHYL-4-OXO-1,8-NAPHTHYRI DINE-3-CARBOXYLIC ACID;1-ETHYL-1,4-DIHYDRO-7-METHYL-4-OXO-1,8-NAPHTHYRI DINE-3-CARBOXYLIC ACID;1-ETHYL-7-METHYL-1,8-NAPHTHYRIDINE-4-ONE-3-CARBO XYLIC ACID;1,8-Naphthyridine-3-carboxylicacid,1